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2. Legal Name*
4. Date of Birth*
   Date of Birth
5. Sex (M/F)*
7. Residence Address*
9. City*
10. State*
11. Zip Code*
13. Mailing Address*
15. City*
16. State*
17. Zip Code*
19. Phone Number*
20. Alternate Phone Number
22. Email*
26. Which Library location would you like to pick your Library Card up from?*
    -- Select One --R.C. Miller LibraryTheodore Johns LibraryElmo Willard LibraryDowntown Main Library
30. I understand that*

    1) I am responsible for all items borrowed with this library card, including late, lost, or damaged materials.

    2)  I will notify the library immediately if the card is lost or stolen.

    3)  I will notify the library of a change of address and/or telephone number. (By City Ordinance, it is unlawful for a non-resident to use the card unless Beaumont city property taxes are paid or an annual non-resident fee is paid.)

    4) I understand that the card is city property and I must return it upon request.

    1. I understand all
32. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
34. Electronic Signature*
36. Employer Name and Address*
38. Photo of Applicant's Driver's License*

    Please upload a scan or photo of your valid Driver's License with your name, face, and address clearly visible. 

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40. Submit

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